Ultrasound Documentation

Ultrasound Documentation

October 4, 2018

Question:
What needs to be documented when I perform a procedure using ultrasound guidance?  The insurance company denied the service after requesting my procedure note saying it was not documented and will not pay for the service.  Are there any guidelines for this?

Answer:
According to the CPT guidelines for Radiology services, all imaging guidance codes which includes ultrasound requires:

  1. Image documentation in the patient’s medical record (permanent record)
  2. Description of imaging guidance in the procedure note of a separate procedure note.

*This response is based on the best information available as of 10/04/18.

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